Hospitals, medical clinics, medical offices, and other sources of medical care typically keep records for their patients. These records include a variety of information such as doctors' notes regarding the patients' complaints and symptoms, diagnoses, notes regarding treatments and procedures administered, patients' drug or other allergies, medicines the patient has been taking, and medicines that are newly prescribed. A great deal of information is thus generated for each patient, and in hospital or clinical environments, where numerous patients are treated, the volume of information generated for all patients can become truly enormous, thus creating an ever present need for more efficient ways of handling the information.
One of the ways that the healthcare industry has developed to manage healthcare information involves the standardization of nomenclature for diagnoses, treatments, medical procedures, medications, and other medical services. Many systems of standardization exist. One system is the International Classification of Diseases (ICD-9, which indicates the 9th revision), published by the World Health Organization. The International Classification of Diseases is a classification structure that provides rules for assigning numeric codes that specify causes of death for death certificates, thus facilitating analysis of mortality statistics. The Center for Disease Control (CDC) has expanded the ICD-9 to include classification codes for diagnoses and procedures for hospitals in the United States. The ICD-9-CM thus provides a clinical modification (CM) to the ICD-9 that includes codes for surgical, diagnostic, and therapeutic procedures, as well as the disease codes of the ICD-9. A recent revision of the ICD, ICD-10 (1999), expands the list of disease codes. The CDC anticipates release of a revision of its clinical modification and has made a draft version of the ICD-10-CM available for review, but no other purposes. Currently only the codes of the ICD-9-CM are in use.
Other systems of medical classification include the Current Procedural Terminology (CPT), published by the American Medical Association (AMA). The CPT provides classification codes for medical diagnoses to provide a uniform language for medical services including surgical, radiological, diagnostic, and therapeutic services, as well as codes for services provided in various medical specialties and laboratory procedures. Another classification system is the Systemized Nomenclature of Medicine (SNOMED), published by the College of American Pathologists (CAP). SNOMED provides detailed and specific classification codes for clinical information and reference terminology and is cross-referenced to the ICD.
Notwithstanding the variety of options available for standardization of medical records, physicians and other healthcare providers rarely use classification codes in creating medical records because classification usually involves significant effort and is not worth the physicians' time. However, healthcare providers are often required to provide standardized medical reports in order to recover expenses from insurance providers. Furthermore, the medical community can benefit from standardized medical records for such purposes as statistical analyses of disease and epidemic containment. Thus healthcare providers typically employ coding specialists, who review patients' medical records, extract information regarding medical services provided, manually look up the classification codes for those services, and annotate the medical record with the codes corresponding to the services provided. These annotated medical records are then provided to insurers for payment for services provided.
One problem that plagues this system is the coding specialists' failure to find all billable services and to provide codes corresponding to those services to insurers. This failure can result in loss of significant revenue to the medical facility. There is therefore a need for a more reliable system of assigning codes to medical records. Coding specialists can benefit from a more complete picture of a patient's medical record, yet they are often asked to analyze a patient's medical history piecemeal, as particular treatments are administered. There is therefore a need for a system which can gather and assemble various documents from various sources within a medical facility in order to provide a more complete picture of that patient's treatment.
An option for increasing the reliability of coding is to add automation to the process. Automated coding systems do exist, the most famous of such systems known as the Gabrieli engine was developed by Dr. Elemér Gabrieli. The Gabrieli engine is a coding engine—a text processor for parsing free medical text, such as that written or dictated by a physician while diagnosing or treating a patient, and translating it into a system of medical codes. The Gabrieli engine sorts through the input medical text, rearranging and tweaking it, searching for a reasonable match of the input medical text to a database of predetermined medical descriptions corresponding to particular classification codes. The Gabrieli engine was revolutionary for its time, but it has significant shortcomings, such as its relatively slow speed, its relative inaccuracy, and its relative inability to learn from prior coding failures. There is therefore a need for improved automated coding systems.